Andrea Natale

University of Texas at Austin, Austin, Texas, United States

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Publications (851)

  • Ranjan K. Thakur · Andrea Natale
    Article · Sep 2016 · Cardiac electrophysiology clinics
  • [Show abstract] [Hide abstract] ABSTRACT: Importance Significant differences have been described between women and men regarding presentation, mechanism, and treatment outcome of certain arrhythmias. Previous studies of ventricular tachycardia (VT) ablation have not included sufficient women for meaningful comparison. Objective To compare outcomes between women and men with structural heart disease undergoing VT ablation. Design, Setting, and Participants Investigator-initiated, multicenter, observational study performed between 2002 and 2013, conducted by the International VT Ablation Center Collaborative Group, consisting of 12 high-volume ablation centers. Consecutive patients with structural heart disease undergoing VT ablation were studied. Structural heart disease was defined as left ventricular ejection fraction less than 55%, hypertrophic cardiomyopathy, or right ventricular cardiomyopathy, with scar confirmed during electroanatomic mapping. Exposures Catheter ablation. Main Outcomes and Measures Ventricular tachycardia–free survival and transplant-free survival were compared between women and men. Cox proportional hazard modeling was performed. Results Of 2062 patients undergoing ablation, 266 (12.9%) were women. Mean (SD) age was 62.4 (13.3) years and 1095 (53.1%) had ischemic cardiomyopathy. Compared with men, women were younger, with higher left ventricular ejection fraction and less VT storm. Despite this, women had higher rates of 1-year VT recurrence following ablation (30.5% vs 25.3%; P = .03). This difference was only partially explained by higher prevalence of nonischemic cardiomyopathy among women and was actually most pronounced among those with ischemic cardiomyopathy. Conclusions and Relevance In 12 high-volume ablation centers, women with structural heart disease have worse VT-free survival following ablation than men. Whether this is owing to differences in referral pattern, arrhythmia substrate, or undertreatment requires further study.
    Article · Aug 2016 · JAMA Cardiology
  • Luigi Di Biase · Andrea Natale
    Article · Aug 2016 · Journal of Interventional Cardiac Electrophysiology
  • Luigi Di Biase · Andrea Natale
    Article · Jul 2016 · Circulation Arrhythmia and Electrophysiology
  • Carola Gianni · Andrea Natale
    Article · Jul 2016 · Heart rhythm: the official journal of the Heart Rhythm Society
  • Carola Gianni · Moustapha Atoui · Sanghamitra Mohanty · [...] · Andrea Natale
    [Show abstract] [Hide abstract] ABSTRACT: No relevant conflicts of interest to disclose.
    Article · Jul 2016
  • [Show abstract] [Hide abstract] ABSTRACT: Intorduction: Medical societies and cardiac implantable electronic devices (CIED) manufacturers recommend avoiding close or direct contact between the body of transvenous leads and ablation catheters used to treat cardiac arrhythmias. These recommendations are made despite the lack of clinical studies. However, the target myocardium for successful ablation can be contiguous to CIED leads. Methods and results: We examine in vitro the effects of direct application of radiofrequency (RF) and cryo-ablation energy on the integrity and functionality of CIED leads (excluding the pacing electrodes and defibrillation coils). A saline bath was created to mimic the body milieu. CIED leads, including all commercially available lead insulation materials, were connected to a CIED pulse generator and placed in direct contact with ablation catheter in the tissue bath. RF and cryo-ablation energy were delivered under various conditions, including maximal ablation power, temperature and impedance via the RF generator. CIED lead functionality, reflective of conductor integrity, was evaluated through lead impedance monitoring during ablation. CIED leads were then visually inspected, and examined with optic and electron microscopy as per protocol. A total of 42 leads were studied. All leads showed absence of insulation damage at the site of ablation visually and with microscopy. Lead functionality was also preserved in all leads. Conclusion: Catheter ablation in contact with CIED leads using radiofrequency or cryo-ablation in vitro did not affect lead body integrity and function despite aggressive ablation settings. It may be reasonable to perform ablation in contact with the body of CIED leads when clinically necessary. This article is protected by copyright. All rights reserved.
    Article · Jun 2016 · Journal of Cardiovascular Electrophysiology
    [Show abstract] [Hide abstract] ABSTRACT: Background: Despite widespread interest and extensive research, the association between different levels of physical activity (PA) and risk of atrial fibrillation (AF) is still not clearly defined. Therefore, we systematically evaluated and summarized the evidences regarding association of different intensity of PA with the risk of AF in this meta-analysis. Methods and results: An extensive literature search was performed on databases for studies showing association of exercise with AF risk. Twenty-two studies were identified that included 656,750 subjects. Meta-analytic estimates were derived using random-effects models and pooled odds ratio estimates were obtained. Potential sources of heterogeneity were examined in sensitivity analyses, and publication biases were estimated. Pooled analysis of 7 studies with 93,995 participants reported high risk of incident AF with sedentary lifestyle [pooled OR 2.47 [95% CI 1.25 to 3.7], p = 0.005]. In 3 trials, 149,048 women involved in moderate PA were 8.6% less likely to develop AF compared to women with sedentary life [OR 0.91 (95% CI 0.78 to 0.97), p = 0.002]. Women performing intense exercise were found to have 28% lower risk of AF [OR 0.72 (95% CI 0.57 to 0.88, p<0.001)]. The overall pooled estimate indicated a protective impact of moderate PA in men [pooled OR 0.8133 (95% CI 0.26 to 1.004), p = 0.06] whereas vigorous PA was associated with a significantly increased AF risk [pooled OR 3.30 (1.97 to 4.63), p = 0.0002]. Conclusion: Sedentary life-style significantly increases and moderate amount of physical activity reduces the risk of AF in both men and women. However, intense exercise has a gender-specific association with AF risk. This article is protected by copyright. All rights reserved.
    Article · Jun 2016 · Journal of Cardiovascular Electrophysiology
  • Ranjan K. Thakur · Andrea Natale
    Article · Jun 2016 · Cardiac electrophysiology clinics
  • [Show abstract] [Hide abstract] ABSTRACT: Background: Pneumothorax (PTX) is a major cause of morbidity associated with cardiac implantable electronic devices (CIED). We sought to evaluate predictors of PTX at our centers during CIED implantations, including the venous access technique utilized, as well as to determine morbidity and costs associated with PTX. Methods: We reviewed records of all patients undergoing cardiac device implant or revision with new venous access at our institutions between 2008 and 2014. Common demographic and procedure characteristics were collected including age, sex, body mass index (BMI), comorbidities, and method of venous access (axillary vein versus classic proximal subclavian vein technique). Results: We identified 1264 patients that met criteria for our analysis, with a total of 21 PTX cases during CIED implantation. The strongest predictor for PTX was the venous access strategy: 0/385 (0%) patients with axillary vein approach versus 21/879 (2.4%) with traditional subclavian vein approach, p = 0.0006. Additional predictors of PTX included advanced age, female sex, low BMI and a new device implant (versus device upgrade). The occurrence of PTX was associated with increased length of stay: 3.0 days [Median; Interquartile Range (IQR) 3] versus 1.0 day [Median; IQR 1], p = 0.0001, with a cost increase of 361.4%. Conclusion: An axillary vein vascular access strategy was associated with greatly reduced risk of iatrogenic pneumothorax versus the traditional subclavian approach for CIED placement. Similarly, device upgrade with patent vascular access carried less risk of pneumothorax compared to new device implantation. Pneumothorax occurrence significantly prolonged hospitalization and increased costs. This article is protected by copyright. All rights reserved.
    Article · May 2016 · Pacing and Clinical Electrophysiology
  • Ranjan K. Thakur · Ziyad M. Hijazi · Andrea Natale
    Article · May 2016
  • Sanghamitra Mohanty · Carola Gianni · Prasant Mohanty · [...] · Andrea Natale
    [Show abstract] [Hide abstract] ABSTRACT: Introduction: Few studies have reported focal impulse and rotor modulation (FIRM)-guided ablation to be superior to PV isolation (PVAI) in persistent (PeAF) and long-standing persistent atrial fibrillation (LSPAF) patients, but none of these trials were randomized. Objectives: We compared the efficacy of FIRM ablation with or without PVAI vs PVAI plus non-PV trigger ablation in PeAF and LSPAF patients. Methods: Non-paroxysmal AF patients undergoing first ablation were randomized (1:1:1) to FIRM only (group 1), FIRM+ PVAI (group 2) or PVAI+ posterior wall (PW) +non-PV trigger ablation (group 3). Freedom from atrial tachycardia (AT)/AF was the primary endpoint. Secondary endpoint included acute procedural success, defined as AF termination or ≥10% slowing or organization into AT. Results: Total of 113 patients were enrolled at 3 centers; 29 in group 1 and 42 in group 2 and 3 each. Enrollment in group 1 was terminated early for futility. Focal drivers or rotors were detected in all group 1 and 2 patients with a mean of 4±1.2 and 4.2± 1.7 per patient in respective groups. Procedure time was 222±49, 233± 48 and 131± 51 minutes in groups 1, 2 and 3 (p<0.001); it was significantly shorter in group 3 compared to groups 1 and 2 (p<0.001). In group 1 and 2, acute success after rotor only ablation was achieved in 12 (41%) and 11 (26%) patients respectively. After 12±7 month follow-up, 4 (14%), 22 (52.4%) and 32 (76%) patients in groups 1, 2 and 3 were AF/AT-free off anti-arrhythmic drugs (log-rank p<0.0001). Group 3 patients experienced higher success compared to group 1 (p<0.001) and group 2(p= 0.02). Conclusion: This is the first randomized study that compared three ablation strategies in non-paroxysmal AF patients and reported a very poor outcome with rotor-only ablation. Moreover, PVAI plus rotor ablation had significantly longer procedure time and lower efficacy than PVAI + PW + non-PV trigger-ablation.
    Article · May 2016 · Journal of the American College of Cardiology
  • [Show abstract] [Hide abstract] ABSTRACT: Background: The safety of digoxin has been a subject of debate for decades, most recently among patients with atrial fibrillation (AF). Digoxin has been used during the acute phase of ST elevation myocardial infarction (STEMI) complicated with AF or heart failure. Data about digoxin in this setting are scarce. Hypothesis: We hypothesize that digoxin maybe associated with increased mortality when used during the acute phase of ST segment myocardial infarction. Methods: We investigated the association between digoxin and mortality in patients enrolled in the MAGnesium In Coronaries (MAGIC) study, which evaluated the efficacy of early magnesium administration in STEMI. Multiple Cox proportional hazards models were examined to assess the aforementioned association after correction for clinical characteristics and comorbidities. Results: After excluding 639 (10.3%) patients for missing data, we analyzed the remaining 5574 patients. There were 852 (15.3%) deaths during the one month follow-up and 170 (3.0%) patients on digoxin concomitantly, among which 42 patients (24.7%) died. There was a statistically significant association between digoxin and increased mortality in the unadjusted statistical analysis; however, this association disappeared after correction for clinical characteristics and comorbidities in the primary multivariable analysis (estimated hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.62-1.19, p=0.372) and in three additional multivariable analyses. Conclusion: Digoxin use as a new or preexisting medication during the acute phase of STEMI in the MAGIC trial was not associated with a significant increase in mortality after correcting for clinical characteristics and comorbidities.
    Article · May 2016 · International journal of cardiology
  • Carola Gianni · Luigi Di Biase · Chintan Trivedi · [...] · Andrea Natale
    [Show abstract] [Hide abstract] ABSTRACT: Objectives The aim of this study was to evaluate the incidence and clinical implications of leaks (acute incomplete occlusion, early and late reopenings) following LAA ligation with the LARIAT device. Background Percutaneous LAA ligation with the LARIAT device may represent an alternative for stroke prevention in high-risk patients with atrial fibrillation with contraindications to oral anticoagulation. Methods This was a retrospective, multicenter study of 98 consecutive patients undergoing successful LAA ligation with the LARIAT device. Leaks were defined as the presence of flow as evaluated by transesophageal echocardiography (TEE). TEE was performed during the procedure, at 6 and 12 months, and after thromboembolic events. Results Leaks were detected in 5 (5%), 14 (15%), and 19 (20%) patients at the 3 time points. During follow-up, 5 patients developed neurological events (4 strokes and 1 transient ischemic attack). Two occurred early (1 fatal stroke and 1 stroke with multiple recurrences in the following months), and TEE was not repeated after the events. The remaining 3 occurred late (after 6 months) and were associated with small leaks (<5 mm). In 2 of 3 cases, such a small leak was missed by the standard evaluation on 2-dimensional TEE, being evident only with the aid of 3-dimensional imaging. Conclusions Incomplete occlusion of the LAA after LARIAT ligation is relatively common and may be associated with thromboembolic events. Proper long-term surveillance with careful TEE should be considered to detect leaks, which can be managed with either resumption of oral anticoagulation or percutaneous transcatheter closure.
    Article · May 2016
  • Article · May 2016
  • Yalçin Gökoğlan · Sanghamitra Mohanty · Mahmut F. Güneş · [...] · Andrea Natale
    [Show abstract] [Hide abstract] ABSTRACT: Background - We report the outcome of pulmonary vein (PV) antrum isolation in paroxysmal atrial fibrillation (AF) patients over more than a decade of follow-up. Methods and Results - A total of 513 paroxysmal AF patients (age 54±11 years, 73% males) undergoing catheter ablation at our institutions were included in this analysis. PV antrum isolation extended to the posterior wall between PVs plus empirical isolation of the superior vena cava was performed in all. Non-PV triggers were targeted during repeat procedure(s). Follow-up was performed quarterly for the first year and every 6 to 9 months thereafter. The outcome of this study was freedom from recurrent AF/atrial tachycardia. At 12 years, single-procedure arrhythmia-free survival was achieved in 58.7% of patients. Overall, the rate of recurrent arrhythmia (AF/atrial tachycardia) was 21% at 1 year, 11% between 1 and 3 years, 4% between 3 and 6 years, and 5.3% between 6 and 12 years. Repeat procedure was performed in 74% of patients. Reconnection in the PV antrum was found in 31% of patients after a single procedure and in no patients after 2 procedures. Non-PV triggers were found and targeted in all patients presenting with recurrent arrhythmia after ≥2 procedures. At 12 years, after multiple procedures, freedom from recurrent AF/atrial tachycardia was achieved in 87%. Conclusions - In patients with paroxysmal AF undergoing extended PV antrum isolation, the rate of late recurrence is lower than what previously reported with segmental or less extensive antral isolation. However, over more than a decade of follow-up, nearly 14% of patients developed recurrence because of new non-PV triggers.
    Article · May 2016 · Circulation Arrhythmia and Electrophysiology
  • Jalaj Garg · Rahul Chaudhary · Parasuram Krishnamoorthy · [...] · Andrea Natale
    [Show abstract] [Hide abstract] ABSTRACT: Background: Aim of our study was to assess the safety and efficacy on factor-Xa inhibitors (FXIs) in patients with non-valvular atrial fibrillation (NVAF) as compared to Vitamin K antagonist (VKA). Methods: Phase II and III randomized controlled trials that reported clinical safety and efficacy of FXI in patients with NVAF were identified from MEDLINE, Embase, and Cochrane Central Register of Controlled Trials through December 10, 2015. The primary safety outcome of our study was composite of stroke and systemic embolic event. Secondary outcomes studied were individual endpoints of primary safety outcome, major bleeding, clinically relevant non-major bleed (CRNMB), and all-cause mortality. Results: We included 11 RCTs with a total of 59,164 participants, of which 34,231 patients received oral FXI and 24,933 patients were on VKA with a mean follow-up of 369days. There was a significant reduction in primary outcome with FXI compared to VKA, 1,112 (3.4%) versus 816 (3.6%) events, respectively (OR 0.82; 95% CI 0.68-0.99). Use of FXI significantly reduced major bleeding events compared to VKA, OR 0.74, 95% CI 0.58-0.96, test for heterogeneity (I(2)=74%). Incidence of CRNMB was not different between FXI and VKA groups, OR 0.84, 95% CI 0.68-1.04. There was a significant reduction in all-cause mortality in FXI group compared to VKA group, OR 0.88, 95% CI 0.83-0.94 with no significant heterogeneity. Conclusion: Use of FXI was associated with a significant reduction in major bleeding events and all-cause mortality without increased risk of stroke or SEE compared to VKA.
    Article · May 2016 · International journal of cardiology
  • Sean C. Beinart · Andrea Natale · Atul Verma · [...] · Suneet Mittal
    [Show abstract] [Hide abstract] ABSTRACT: Background: The use of prophylactic antibiotics during insertable cardiac monitor (ICM) procedures is a carryover of the common practice used with therapeutic cardiac implantable electronic devices. We sought to characterize the current practice of ICM insertion procedures to evaluate the influence of prophylactic antibiotic administration on the occurrence of infections. Methods: We characterized insertion procedures and procedure-related infections from an ongoing multicenter registry (Reveal LINQ™ Registry). In order to accurately capture infections, only patients enrolled before or the day of insertion who also had a record of whether or not preoperative antibiotics were used were included in this analysis. Infections were defined based on the physician's assessment and reported upon occurrence. Patients were categorized into two analysis cohorts based on prophylactic antibiotic use. Results: We analyzed 375 patients from 14 US centers (age 63.1±15.6 years; male 54.1%). Approximately two-thirds of patients (66.4%) did not receive any pre-procedural antibiotics. The overall infection rate was 1.1% (0.3%-2.7% CI) and corresponded to four events. In the group that did not receive pre-procedural antibiotics there were two minor infections (0.8%, (0.1%-2.9% CI)), whereas in the group receiving pre-procedural antibiotics a serious and a minor infection occurred (1.6%, (0.2%-5.6% CI)); this serious infection resulted in an explant. Conclusions: Current real-world practice shows that ICM insertions are increasingly performed without the use of prophylactic antibiotics, which is associated with a very low infection rate. This article is protected by copyright. All rights reserved.
    Article · May 2016 · Pacing and Clinical Electrophysiology
  • Source
    Full-text Article · Apr 2016 · Journal of the American College of Cardiology
  • Sanghamitra Mohanty · Amelia Hall · Prasant Mohanty · [...] · Andrea Natale
    Article · Apr 2016 · Journal of the American College of Cardiology

Publication Stats

23k Citations


  • 2015
    • University of Texas at Austin
      • Department of Biomedical Engineering
      Austin, Texas, United States
    • Massachusetts General Hospital
      Boston, Massachusetts, United States
    • St. David's North Austin Medical Center
      Austin, Texas, United States
  • 2011-2015
    • Texas Research Institute Austin, Inc
      Austin, Texas, United States
  • 2011-2014
    • Michigan State University
      • Thoracic and Cardiovascular Institute
      East Lansing, Michigan, United States
  • 2012
    • Ospedale Luigi Sacco
      Milano, Lombardy, Italy
    • Southlake Regional Health Centre
      Bradford West Gwillimbury, Ontario, Canada
  • 2008
    • Beth Israel Medical Center
      New York, New York, United States
    • Università degli studi di Foggia
      Foggia, Apulia, Italy
  • 2007
    • Cleveland Clinic Laboratories
      Cleveland, Ohio, United States
  • 2006
    • Catholic University of the Sacred Heart
      Milano, Lombardy, Italy
    • IRCCS Ospedale Casa Sollievo della Sofferenza
      Giovanni Rotondo, Apulia, Italy
  • 2000-2004
    • Cleveland Clinic
      • Department of Cardiology
      Cleveland, Ohio, United States
  • 1995
    • Duke University
      Durham, North Carolina, United States
    • Duke University Medical Center
      • Division of Cardiology
      Durham, North Carolina, United States
  • 1991
    • Robarts Research Institute
      London, Ontario, Canada